COVID-19 Vaccine CPT Updates for September and October 2021

Third Dose of Moderna COVID-19 vaccine CPT code has been released,

0013A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose

Other administration codes are, 

0011A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose

0012A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose

Vaccine CPT Code

91301- Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use

October '2021 

Accepted three Category I codes to report SARS-CoV-2 vaccine and immunization administration codes. 

Codes 91307, 0071A, and 0072A are used to report Pfizer COVID-19 vaccine and immunization administration for the tris-sucrose pediatric for patient age 5 through 11 years.

These codes were published on Oct. 6, 2021 and will be effective upon receiving Emergency Use Authorization or approval from the Food and Drug Administration.

September '2021

Accepted eight Category I codes to report SARS-CoV-2 vaccine and immunization administration codes. 

Codes 91305, 0051A, 0052A and 0053A are used to report Pfizer COVID-19 vaccine and immunization administration for the tris-sucrose formulation. 

Codes 0004A and 0054A are used to report Pfizer COVID-19 immunization administration booster doses for both available formulations. 

Codes 91306 and 0064A are used to report Moderna COVID-19 vaccine and immunization administration booster doses. 

Appendix Q has been updated to reflect these additions. These codes were published on Sept. 3, 2021 and will be effective upon receiving Emergency Use Authorization or approval from the Food and Drug Administration.

Hepatitis C Virus (HCV) Screening

HCPCS/CPT Codes

• G0472 – Hepatitis C antibody screening, for individual at high risk and other covered indication(s)

Covered ICD-10 Codes

The specified below ICD codes are covered for CPT G0472 and may not be limited and some private payers have own specific guidelines,

• B17.10 Acute hepatitis C without hepatic coma
• B17.11 Acute hepatitis C with hepatic coma
• B18.2 Chronic viral hepatitis C
• B18.8 Other chronic viral hepatitis
• B18.9 Chronic viral hepatitis, unspecified
• B19.20 Unspecified viral hepatitis C without hepatic coma
• B19.21 Unspecified viral hepatitis C with hepatic coma
• B19.9 Unspecified viral hepatitis without hepatic coma
• B25.1 Cytomegaloviral hepatitis
• F19.20 Other psychoactive substance dependence, uncomplicated
• O98.411 Viral hepatitis complicating pregnancy, first trimester
• O98.412 Viral hepatitis complicating pregnancy, second trimester
• O98.413 Viral hepatitis complicating pregnancy, third trimester
• O98.419 Viral hepatitis complicating pregnancy, unspecified trimester
• O98.42 Viral hepatitis complicating childbirth
• O98.43 Viral hepatitis complicating the puerperium
• Z72.51 High risk heterosexual behavior
• Z72.52 High risk homosexual behavior
• Z72.53 High risk bisexual behavior
• Z72.89 Other problems related to lifestyle

Who Is Covered

Certain adult Medicare beneficiaries who fall into at least one of the following categories,

• High risk for HCV infection
• Born between 1945 and 1965

Frequency

• Annually only for high risk Medicare beneficiaries with continued illicit injection drug use since the prior negative screening test
• Once in a lifetime for Medicare beneficiaries born between 1945 and 1965 who are not considered high risk

Medicare Beneficiary Pays

• Co-payment/coinsurance waived
• Deductible waived

Annual Wellness Visit (AWV) - Medicare

 HCPCS/CPT Codes

• G0438 – Annual wellness visit; includes a personalized prevention plan of service (PPPS), initial visit
• G0439 – Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit

Who Is Covered

All Medicare beneficiaries who are both,

• Not within 12 months after the effective date of their first Medicare Part B coverage period
• Have not received an Initial Preventive Physical Examination (IPPE) or AWV within the past 12 months

Frequently Used ICD

• Z00.00 - Encounter for general adult medical examination without abnormal findings
• Z00.01 - Encounter for general adult medical examination with abnormal findings
• Z00.121 - Encounter for routine child health examination with abnormal findings
• Z00.129 - Encounter for routine child health examination without abnormal findings

Frequency

• Once in a lifetime for G0438 (first AWV)
• Annually for G0439 (subsequent AWV)

Medicare Beneficiary Pays

• Co-payment/Coinsurance waived
• Deductible waived

CMS Will Pay for COVID-19 Booster Shots

Coverage without cost-sharing available for eligible people with Medicare, Medicaid, CHIP, and Most Commercial Health Insurance Coverage

Following the FDA recent action that authorized a booster dose of the Pfizer COVID-19 vaccine for certain high-risk populations and a recommendation from the CDC, CMS will continue to provide coverage for this critical protection from the virus, including booster doses, without cost sharing.

Beneficiaries with Medicare pay nothing for COVID-19 vaccines or their administration, and there is no applicable co-payment, coinsurance, or deductible. 

In addition, thanks to the American Rescue Plan Act of 2021, nearly all Medicaid and CHIP beneficiaries must receive coverage of COVID-19 vaccines and their administration, without cost-sharing. COVID-19 vaccines and their administration, including boosters, will also be covered without cost-sharing for eligible consumers of most issuers of health insurance in the commercial market. 

CMS continues to explore ways to ensure maximum access to COVID-19 vaccinations

New COVID-19 Vaccine Codes - September'2021

Immunization Administration 

0001A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; first dose.

0002A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; second dose.

0003A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; third dose.

0004A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, diluent reconstituted; booster dose.

• Report 0001A, 0002A, 0003A, 0004A for the administration of vaccine 91300

0051A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; first dose.

0052A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; second dose.

0053A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; third dose.

0054A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation; booster dose.

• Report 0051A, 0052A, 0053A, 0054A for the administration of vaccine 91305

0011A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; first dose.

0012A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; second dose.

0013A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5 mL dosage; third dose.

• Report 0011A, 0012A, 0013A, for the administration of vaccine 91301

0064A - Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 50 mcg/0.25 mL dosage, booster dose.

• Report 0064A for the administration of vaccine 91306

Expand Vaccination Requirements

The overall will protect patients of the 50,000 providers and over 17 million health care workers in Medicare and Medicaid certified facilities for COVID-19 Vaccines.

The Centers for Medicare & Medicaid Services (CMS), in collaboration with the Centers for Disease Control and Prevention (CDC), announced that emergency regulations requiring vaccinations for nursing home workers will be expanded to include,

• Hospitals, 
• Dialysis facilities, 
• Ambulatory surgical settings, 
• Home health agencies.

Nursing homes with an overall staff vaccination rate of 75% or lower experience higher rates of preventable COVID infection. 

In CMS review of available data, the agency is seeing lower staff vaccination rates among hospital and End Stage Renal Disease (ESRD) facilities. 

To combat this issue, CMS is using its authority to establish vaccine requirements for all providers and suppliers that participate in the Medicare and Medicaid programs. 

Vaccinations have proven to reduce the risk of severe illness and death from COVID-19 and are effective against the Delta variant.

CMS is developing an Interim Final Rule with Comment Period that will be issued in October.  

CMS expects certified Medicare and Medicaid facilities to act in the best interest of patients and staff by complying with new COVID-19 vaccination requirements.  

Health care workers employed in these facilities who are not currently vaccinated are urged to begin the process immediately. 

Facilities are urged to use all available resources to support employee vaccinations, including employee education and clinics, as they work to meet new federal requirements.

Conventions and General Coding Guidelines - PART 3

Continuation of PART 2

Etiology/Manifestation Convention

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the  ICD-10-CM  has a  coding convention that requires the underlying condition to be sequenced first, if applicable, followed by the manifestation. 

Wherever such a  combination exists,  there is a “use additional code” note at the etiology code,  and a “code first” note at the manifestation code. These instructional notes indicate the proper sequencing order of the codes,  etiology followed by manifestation. 

In  most cases, the manifestation codes will have in  the code  title,  “in  diseases classified elsewhere.”  Codes with this title are components of the etiology/ manifestation convention. 

There are manifestation codes that do not have  “in diseases classified elsewhere” in the title. For such codes,  there is a  “use additional code” note at the etiology code and a “code first” note at the manifestation code,  and the rules for sequencing apply.

“Code first”  and  “Use additional code” notes are also used as sequencing rules in the classification for certain codes that are not part of an etiology/ manifestation combination. 

And

The word “and” should be interpreted to mean either “and” or “or” when it appears in a title. For example, cases of  “tuberculosis of bones”, “tuberculosis of joints”  and “tuberculosis of bones and joints” are classified to subcategory  A18.0, Tuberculosis of bones and joints.

With 

The word “with” or “in” should be interpreted to mean “associated with” or “due to” when it appears in a code title,  the Alphabetic Index  (either under the main term or subterm),  or an instructional note in the Tabular  List.  

The classification presumes a causal relationship between the two conditions linked by these terms in the  Alphabetic Index or  Tabular  List.  

These conditions should be coded as related even in the absence of provider documentation explicitly linking them unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a  documented linkage between two conditions  

(e.g.,  sepsis guideline for  “acute organ dysfunction that is not clearly associated with the sepsis”). 

Code Also Note

A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.  The sequencing depends on the circumstances of the encounter.

Default Codes 

A code listed next to a main term in the ICD-10-CM Alphabetic  Index is referred to as a default code The default code represents that condition that is most commonly associated with the main term or is the unspecified code for the condition. If a condition is documented in a  medical record  (for example, appendicitis) without any additional information,  such as acute or chronic, the default code should be assigned.